Age: the least important number?
Authors: None The Lancet Healthy Longevity
Journal: The Lancet Healthy Longevity (2020)

Nov 14, 2020, marked World Diabetes Day. First launched in 1991, this day was a little different in 2020. Although global incidence of type 2 diabetes continues to increase, the world's focus is elsewhere, watching the unfolding tragedy of the COVID-19 pandemic. At first glance, the two diseases seem utterly dissimilar: one is a viral infection with unknown pathogenesis, the other a well-studied non-communicable disease. However, notably, the two share at least one aspect: both appear to increase with age. The Lancet Commission on diabetes, published on this year's World Diabetes Day, notes that one factor driving the global diabetes epidemic is demographic ageing: the increasing proportion of the population comprised of older people. Similarly, COVID-19 appears to have such worse outcomes for older people that some countries—including the UK—recommended that those over a certain age isolate themselves entirely as a means of protection. We accept these recommendations because it is still widely held that age alone is the determining factor in health. To be older than a certain age is seen, automatically, as being vulnerable, yet this is to confuse chronological age with something more nuanced, complex, and important: frailty. Frailty can be defined as “a state of increased vulnerability to poor resolution of homeostasis after a stressor event which increases the risk of adverse outcomes”. In other words, it is a multi-faceted and complex clinical syndrome which acts to reduce an individual's resilience. Data clearly show that people who are frail have worse outcomes following even minor stressors than those who are not frail. Frail people have a substantially increased risk of developing disabilities, needing long-term care, and of death. There is a strong association between frailty and age. Frailty can develop as a consequence of age-related decline, with between 25–50% of people older than 85 years estimated to be frail. However, to be older is not automatically to be frail, despite the conflation of the two. Frailty arises from an interplay of multiple factors, including social, genetic, physiological, and environmental causes. Age, in this context, is simply another risk factor for the development of frailty. The implications of this can be seen when looking at outcomes for patients with both diabetes and COVID-19. In this issue, we publish a systematic review and meta-analysis of frailty measurement, prevalence, incidence, and clinical implications of people with diabetes. This analysis found that frailty is consistently associated with a range of adverse outcomes in people with diabetes, including mortality, hospital admission, disability, and lower quality of life. Similarly, a recently published observational cohort study assessing the effect of frailty on survival in patients with COVID-19 found that disease outcomes were better predicted by frailty than by either age or comorbidity. Assessing frailty in both diseases can allow physicians to make the most appropriate intervention decisions. Equating age and frailty is short-sighted at best and actively harmful at worst. To view older people as intrinsically frail is harmful in multiple ways. First, assumptions of age-related frailty can lead to older patients being undertreated compared with younger patients. For example, treatment of older patients with cancer by chemotherapy has historically been complicated by questions of functional status, comorbidities, life expectancy, and tolerance. However, in this issue, we publish alongside our sister journal The Lancet Oncology two papers showing that women aged 70 and older with triple negative breast cancer have significantly better survival outcomes when given additional chemotherapy as part of their treatment. Second, assuming that it is only older people who are at risk of frailty risks ignoring the warning signs in younger patients. Potentially concerning data are accumulating showing that the proportions of middle-aged people who are frail are rising. At least the possibility of frailty should be included into routine assessments of middle-aged people—for example, with diabetes—for whom frailty can affect treatment outcomes. Finally, equating age and frailty is to indulge in ageism, whereby people dismiss others on the basis of their age, irrespective of their abilities and needs. Viewing older people's needs and abilities solely on the basis of age not only risks giving inappropriate care but can diminish their humanity and autonomy. Just as younger people might be frail, older people might not be. The time has come for both society and medicine to recognise something cliché as true: age is just a number. The Lancet Commission on diabetes: using data to transform diabetes care and patient lives2020 will go down in history as the year when the global community was awakened to the fragility of human health and the interdependence of the ecosystem, economy, and humanity. Amid the COVID-19 pandemic, the vulnerability of people with diabetes during a public health emergency became evident by their at least 2 times increased risk of severe disease or death, especially in individuals with poorly controlled diabetes, comorbidities, or both. The disease burden caused by COVID-19, exacerbated by chronic conditions like diabetes, has inflicted a heavy toll on health-care systems and the global economy. Full-Text PDF Addition of chemotherapy to local therapy in women aged 70 years or older with triple-negative breast cancer: a propensity-matched analysisThese data support consideration of chemotherapy in the treatment of women aged 70 years or older with triple-negative breast cancer. Full-Text PDF The effect of frailty on survival in patients with COVID-19 (COPE): a multicentre, European, observational cohort studyIn a large population of patients admitted to hospital with COVID-19, disease outcomes were better predicted by frailty than either age or comorbidity. Our results support the use of CFS to inform decision making about medical care in adult patients admitted to hospital with COVID-19. Full-Text PDF Open AccessFrailty measurement, prevalence, incidence, and clinical implications in people with diabetes: a systematic review and study-level meta-analysisThe identification and assessment of frailty should become a routine aspect of diabetes care. The relationship between frailty and glycaemia, and the effect of frailty in specific groups (eg, middle-aged [aged <65 years] people and people in low-income and lower-middle-income countries) needs to be better understood to enable diabetes guidelines to be tailored to individuals with frailty. Full-Text PDF Open AccessCOVID-19 and health care inaccessibility in sub-Saharan AfricaThe first case of COVID-19, the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), in sub-Saharan Africa was confirmed in Nigeria on Feb 27, 2020, followed by the first regional death in Burkina Faso on March 18, 2020.1 Since these initial events, more than 1 million cases and 20 000 deaths have been confirmed in the region.2 Despite initial fears of catastrophic spread and high mortality of COVID-19 in Africa, mainly because of high frequencies of HIV and tuberculosis co-infections in combination with weak health systems,1 the toll of the pandemic has remained lower than expected. Full-Text PDF Open Access